The role of overnight pulse oximetry in risk stratification of paediatric sleep disordered breathing in a district general hospital.

OBJECTIVES: Adenoidectomy and tonsillectomy are common surgical interventions in paediatric patients with sleep disordered breathing. Post operative respiratory complications are a recognised risk, and pre-operative risk stratification of patients is important to enable safe delivery of peri-operative care. Due to easy accessibility, overnight pulse oximetry is commonly used for this purpose. However, its limitations have been widely reported and recent national guidance recommends limiting use to patients with significant risk factors. We reviewed the use of overnight pulse oximetry in our local unit to determine if local guidelines should be adapted in line with these national recommendations. METHODS: Retrospective analysis of all paediatric patients referred for overnight pulse oximetry over an eighteen month period between August 2020 to February 2022. Data collection included patient age, weight, and relevant co-morbidities. The McGill score was used to risk stratify patients and determine the need for an overnight bed. This was then correlated with the occurrence of post operative respiratory complications. RESULTS: 200 patients were referred for overnight pulse oximetry, with a mean age of 7.5 years. 7.5 % (15/200) had significant comorbidities. 64 % (128/200) of patients were subsequently listed for surgery. 20.3 % (26/128) were deemed at risk of post-operative complications due to McGill scores of 3 and 4 and planned for overnight ward observation. Of these, 15 % (4/26) were subsequently discharged the same day. None of our patients developed major respiratory complications in the post operative period. CONCLUSION: Our findings support national recommendations that overnight pulse oximetry is not an accurate predictor of post-operative respiratory complications and resulted in unnecessary inpatient stays. Following discussion with the trust paediatric anaesthetist lead, our local guidance was tightened, limiting overnight pulse oximetry to children with relevant identifiable co-morbidities.

Recurrent transient loss of airway secondary to regurgitated pedunculated hypopharyngeal liposarcoma.

We describe a rare case of hypopharyngeal liposarcoma with an atypical presentation. The patient presented with a 3-month history of intermittent, transient acute airway obstruction. In between episodes, he was asymptomatic. A pedunculated tumour originating in the postcricoid region was seen to be suspended into the oesophagus and intermittently regurgitated into the larynx to cause airway obstruction. The lesion was endoscopically removed and examined histologically to confirm the diagnosis. On-going management of rare lesions such as this should be through multidisciplinary team meetings at a tertiary sarcoma centre.

The management of periorbital cellulitis secondary to sinonasal infection: a multicenter prospective study in the United Kingdom.

BACKGROUND: Periorbital cellulitis is a potential sight-threatening complication of sinusitis. The majority of patients improve with medical management. Previous studies have suggested significant variations in practice and lack of evidence regarding the optimal management of this condition. METHODS: A prospective study was conducted over a 12-month period at 8 centers in the United Kingdom assessing the management of patients requiring inpatient treatment for periorbital cellulitis secondary to sinonasal infections. RESULTS: A total of 143 patients were recruited, of whom 40 were excluded. Of the remaining 103 patients, 5 (4.9%) were diagnosed with neurosurgical complications. This resulted in 98 patients admitted with periorbital cellulitis secondary to an upper respiratory tract infection/sinusitis. A total of 72 were children, of whom 12 (16.7%) required surgical intervention; and of 26 adults, 5 (19.2%) required surgery: the most common antimicrobial regimes administered were intravenous ceftriaxone (with or without metronidazole), and co-amoxiclav. The use of both ceftriaxone and metronidazole from admission was associated with the shortest duration of inpatient stay (3.8 days) in comparison to ceftriaxone alone (5.8 days) or co-amoxiclav (4.5 days) and a reduction in number of patients requiring surgical intervention. There was also an association between the early use of intranasal decongestants and steroids and reduction in requirement for surgical intervention. CONCLUSION: For a condition where swab and blood cultures are often negative, this study supports the use of ceftriaxone in combination with metronidazole. The administration of intranasal decongestants and corticosteroids correlated with a smaller percentage of those progressing to surgery in those with and without periorbital abscesses.

Do salivary bypass tubes lower the incidence of pharyngocutaneous fistula following total laryngectomy? A retrospective analysis of predictive factors using multivariate analysis.

Salivary bypass tubes (SBT) are increasingly used to prevent pharyngocutaneous fistula (PCF) following laryngectomy and pharyngolaryngectomy. There is minimal evidence as to their efficacy and literature is limited. The aim of the study was to determine if SBT prevent PCF. The study was a multicentre retrospective case control series (level of evidence 3b). Patients who underwent laryngectomy or pharyngolaryngectomy for cancer or following cancer treatment between 2011 and 2014 were included in the study. The primary outcome was development of a PCF. Other variables recorded were age, sex, prior radiotherapy or chemoradiotherapy, prior tracheostomy, type of procedure, concurrent neck dissection, use of flap reconstruction, use of prophylactic antibiotics, the suture material used for the anastomosis, tumour T stage, histological margins, day one post-operative haemoglobin and whether a salivary bypass tube was used. Univariate and multivariate analysis were performed. A total of 199 patients were included and 24 received salivary bypass tubes. Fistula rates were 8.3% in the SBT group (2/24) and 24.6% in the control group (43/175). This was not statistically significant on univariate (p value 0.115) or multivariate analysis (p value 0.076). In addition, no other co-variables were found to be significant. No group has proven a benefit of salivary bypass tubes on multivariate analysis. The study was limited by a small case group, variations in tube duration and subjects given a tube may have been identified as high risk of fistula. Further prospective studies are warranted prior to recommendation of salivary bypass tubes following laryngectomy.

Audiologic changes after pinna augmentation.

No studies to date have objectively assessed whether pinna morphology affects sound intensity detected within the external auditory canal (EAC). Commonly performed procedures on the EAC are carried out for acquired and congenital pathology, together with correction of ear deformities. Our aim was to use an experimental model to identify whether a relationship exists between pinna shape and its subsequent effect on the hearing subject. An anatomically accurate and life-size model made of rubber composite was used for this study. Serial sections (small wedge, defect open; small wedge, defect closed; large wedge, defect open; large wedge, defect closed [equivalent to a protruding ear]; and pinnectomy) were undertaken, and the sound intensity changes assessed at the junction between the EAC and middle ear (tympanic membrane position) using an AURICAL Plus (Otometrics; Taastrup, Denmark) sound processor. A statistically significant loss was demonstrated for wedge-excised models, which was greatest at 180° azimuth. This loss was significantly reduced when the wedge defects were closed. A statistically significant improvement was demonstrated in the protruding ("bat") ear model compared with the normal ear at 0° azimuth. In this model, gain in sound intensity is adversely affected by pinna wedge resection. Because this change may be increased in those with protruding ears, this factor is important to consider for all cosmetic and noncosmetic operations to the pinna, and it supports the notion that the pinna is not a simple funnel.

Feasibility of adapting a classroom balance training program to a video game platform for people with Parkinson's disease.

OBJECTIVE: Decreased postural stability in people with Parkinson's disease (PD) is a major component of disability. Rehabilitation interventions are therefore targeted to improve balance, mobility, and strength. Virtual environment and gaming platforms can encourage therapeutic activity in the home and be challenging and fun. The aims of the project were to demonstrate the technical feasibility of adapting a classroom-based gait-and-balance training program to a video game platform. Ease of use, appeal, and safety of the proposed games were tested for both clinic and in-home use. SUBJECTS AND METHODS: This cross-sectional observational study was carried out in three phases. Modifications in the game platform were made in an iterative fashion based on feedback from subjects and the observations of clinical and design team members. The first two phases of testing were performed in a laboratory setting, and the final phase was carried out in subjects' homes. RESULTS: Subjects (n=20) scored the primary "Rail Runner" game 3.6 for ease of use (1=hard, 5=easy) and 3.9 for appeal (1=did not like at all, 5=liked very much). There were no safety issues encountered, and the games performed without technical flaws in the final phase of testing. CONCLUSIONS: A computer-based video game that incorporates therapeutic movements to improve gait and balance for people with PD was appealing to subjects and feasible for home use.

Feasibility of Computer-Based Videogame Therapy for Children with Cerebral Palsy.

OBJECTIVES: Standing and gait balance problems are common in children with cerebral palsy (CP), resulting in falls and injuries. Task-oriented exercises to strengthen and stretch muscles that shift the center of mass and change the base of support are effective in improving balance. Gaming environments can be challenging and fun, encouraging children to engage in exercises at home. The aims of this project were to demonstrate the technical feasibility, ease of use, appeal, and safety of a computer-based videogame program designed to improve balance in children with CP. MATERIALS AND METHODS: This study represents a close collaboration between computer design and clinical team members. The first two phases were performed in the laboratory, and the final phase was done in subjects' homes. The prototype balance game was developed using computer-based real-time three-dimensional programming that enabled the team to capture engineering data necessary to tune the system. Videogame modifications, including identifying compensatory movements, were made in an iterative fashion based on feedback from subjects and observations of clinical and software team members. RESULTS: Subjects (n=14) scored the game 21.5 out of 30 for ease of use and appeal, 4.0 out of 5 for enjoyment, and 3.5 on comprehension. There were no safety issues, and the games performed without technical flaws in final testing. CONCLUSIONS: A computer-based videogame incorporating therapeutic movements to improve gait and balance in children with CP was appealing and feasible for home use. A follow-up study examining its effectiveness in improving balance in children with CP is recommended.